Pain Management Is a Primary Target for RA Treatment Plans

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Treating pain is a challenge for RA patients and doctors alike. Once considered an unfortunate side effect of the disease, pain management has now taken center stage in treatment regimens.

Extraordinary advances in pain research over the last decade are helping rheumatologists manage RA pain. Our expert guest, Dr. Mary-Ann Fitzcharles of McGill University, explains how pain has become a primary target for pharmacological and nonpharmacological treatment for those living with rheumatoid arthritis.

What Causes Rheumatoid Arthritis Pain?

Dr. Fitzcharles:

We've experienced pain through millennia, and over the years we've been taught to be stoic and to grin and bear it and just carry on. And I think we've begun to realize that pain has a very, very important impact upon our overall well?being, and maybe the correct answer is no longer to just grin and bear it. Researchers and clinicians and patients have now developed a new awareness of the importance of the impact of pain: to the body, to the person and to everyone else around us. So we're beginning to take much more notice of this very important symptom.

If we go back to about 30 or 40 years ago, when someone developed rheumatoid arthritis the focus was on, first of all, finding the cause or the trigger and, secondly, finding the cure. In the last 20 years, we've become quite good at modulating this disease, and now our focus has been on reducing the inflammatory disease and trying to prevent the damage. And we've really ignored this symptom of pain. We've focused so much on getting the disease under control. And it's suddenly become a new revelation to us that pain is so very important in this condition.

Rheumatic pain originates when there is some damage to a joint, and damage originates when there is an inflammatory process. Essentially, rheumatic pain begins with damage locally in the tissue, and nerve messages move up to the spinal cord and up to the brain.

When we think of reducing our pain, we think of taking a pill such as codeine that dampens down pain, but we have similar molecules in our own body that dampen down pain. So it's pain input that's important, and how our brain and our nervous system respond to control that pain.

With chronic pain, there is a change in which nerves become sensitized much like if you've had some sunburn. If you've had sunburn, just simply touching the skin is painful. In patients with arthritis, just simply moving a knee joint will induce pain. The whole nervous system is fired up and really moves into overdrive.

How Do Physicians Measure RA Pain?

Dr. Fitzcharles:

We're not very good at measuring pain because we really are totally dependent upon what the patient tells us, and every patient's perception is different. So we rely upon the patient telling us how much pain they have, and we use a little scale of one to 10. And many people don't truly understand what we're saying when we're saying is your pain five out of 10 or is it eight out of 10. We try to tell a patient that 10 out of 10 is the most extreme pain you can imagine and zero out of 10 is no pain. So this is called the visual analog scale.

We can also use different types of questionnaires. There are some questionnaires that we can give to patients, but that takes time and the patients get irritated filling in too many questionnaires. But, again, it is very subjective.

We do not have a single blood test or a chemical that can tell us how much pain a patient actually is feeling. In the research setting, we now have very good techniques that are showing the brain circulation and the metabolic activity in areas of the brain that might be activated during pain, but this is a research tool. It's not something that we are able to use in the clinical setting.

Can RA Pain Be Treated Without Medications?

Dr. Fitzcharles:

We still do hand our patients prescriptions for medication when we treat pain. It's the easy way out. But there are many other good mechanisms that we can use. And the simple thing that any patient can use in their own home are things like distraction, listening to a good piece of music, moving away out of your body, taking up a hobby, doing something where your attention is focused away from your pain.

We can also use mechanisms to reduce stress, and to help with depression. Stress accentuates and aggravates pain. If the kids drive you crazy, this might be the time to say, 'I'm going to sit down and had have a nice relaxing cup of tea.' We talked about the value of exercise, and there is no question that exercise, even for patients with important joint disease, is very, very advantageous.

And finally, we should look for the positive things in life. We should look toward the glass being half-full rather than half-empty. Many people tend to be very negative and just look on the dark side, and I think if we try and put a positive spin on our lives and say, 'Well, what's good about this,' it all helps to smooth things over quite a lot.

Setting Realistic Treatment Goals for RA

Dr. Fitzcharles:

The first thing that a patient who has a chronic disease must acknowledge is that I have changed, I am different now, and that means that the goals and objectives have to be reset. And it's very important for people to have realistic outcome goals. We are not living in a utopian world, unfortunately. We can't cure everything. And in the confines of living with a chronic disease, one can still keep life going.

The treatment goal should be really a contract between the physician and the patient, and the aim should be to do the best we can to get the disease under the best control possible. But sometimes even in the most perfect medical setting, we do have patients whose disease just is very, very difficult to manage. And within the confines of those treatments, we so want the patient to live a fulfilling and a happy life within their family, within their social milieu.

The patient's coping mechanisms and how they manage their life become very important in how they are able to move forward. It's one thing to sit and crawl up into a little ball in a corner and say, 'This is the most awful that's happened to me,' but one has still got to keep going, one has got to look positive and one has got to look for the good things in life.

Using Exercise to Control RA Pain

Dr. Fitzcharles:

Exercise has a wonderful effect because exercise does things both for the brain as well as for the muscles and the tissues. Exercise will condition muscles. It will improve the circulation in the muscles. It will remove toxic products. It doesn't only work on muscles. We know it's good for the cardiovascular system.

However, exercise does a second thing, and you can ask anyone who's done a good workout, and they'll tell you, 'I just feel so good.' And what exercise has done is released natural pain inhibitory mechanisms. It also has effects upon the chemicals in our brain that are important for our mood, such as norepinephrine, serotonin and the endogenous opioids (endorphins). So exercise is probably one of the best things we can do for ourselves.

Exercise has an important impact on improving blood circulation, improving muscle tone, improving our psychological well?being and producing pain inhibitory mechanisms. We have more and more evidence for patients with joint disease that their outcome is infinitely better if they remain physically active.

That doesn't mean that they've got to start going to a gym or that they must start marathon running. You have to choose the exercise activity that is pleasant, comfortable and that's enjoyable, and it becomes part of your lifestyle. I really strongly recommend that people move away from being dependent upon healthcare professionals. Physiotherapists are wonderful people and wonderful people to get you onto a track, but it should not be that you become totally dependent upon your physiotherapist to supervise your exercise program every week for the next 10 years. We want patients to become self?sufficient and to find the activity that is enjoyable, and that they're able to sustain.

Choose the activity that is comfortable for you to do. One of the most wonderful places to exercise if someone has painful joints is in water. Water takes away gravity, so you're able to float. It feels so good, and joints will actually increase their range of motion in water. However, if you hate water, there's no value in trying to get into water and to exercise there. So, again, use the activity that you enjoy doing. It might be tai chi, it might be doing a yoga program. It might be joining a low?impact aerobics program. But do what is enjoyable. Listen to your body. Expect to have a little bit of discomfort when you do exercise. Because if you're not having any discomfort, then you're really not doing very much. But we do not want you to feel extreme of pain. So do something that's enjoyable but listen to your body. Be sensible.

How Healthy Eating Can Ease RA Pain

Dr. Fitzcharles:

Let's talk about diet. And, in fact, we've become quite lazy with regard to eating habits. Good food, good protein intake, good fruits and vegetables will give us energy, will give us good natural antioxidants, and there is more and more evidence now that it actually impacts our overall well being and our inflammatory response. So what we eat is what we become.

We want patients to not overeat, to keep their weight within a reasonable range. We don't want people to be obese. And also if you skip meals, you start feeling more and more fatigued. It's amazing how often a patient will say, 'I'm just so terribly fatigued.' And when we explore how they are eating, we find they're skipping meals or they're eating just carbohydrates, a little bit of cereal for breakfast and no protein. So we have to think of a good balanced diet and regular meals.

This is a lovely opportunity to talk a little bit about the omega 3 oils and their value. When we eat substances such as omega 3, which we find in natural fatty fish like salmon and sardines and tuna, these omega 3 fatty acids actually become incorporated into the walls our of our cells, and the walls of our cells eventually make the inflammatory cytokines. If we have incorporated a particular type of molecule into our cells, particularly the omega 3, the inflammatory molecule that is produced is not quite as full and vigorous as it is if we were taking a lot of omega 6 fatty acids. So there is no question that by adding omega 3 we actually slightly reduce the inflammatory response.

Can it work as a supplement? Well, yes it can. It does tend to be a little pricey because you need to eat many, many capsules of oil. And many patients claim that they taste a little fishy as the day goes on. But it's just a good idea to incorporate a good amount of fish into your diet rather than going crazy about supplements.

Will Sleep Decrease Your Rheumatoid Arthritis Pain?

Dr. Fitzcharles:

Having a good, rested sleep and waking up refreshed is a wonderful gift. Many patients will say that they just don't sleep at all. But when we explore this, we find that they climb into bed at 8 o'clock at night or 9 o'clock at night expecting to sleep and get out of bed at 7 o'clock in the morning. What we need is a good six to seven hours of solid sleep, which means that you get into bed when you're tired, you fall asleep, and you wake up in the morning, and once you're awakened you're up and out of bed - no napping during the day.

This is very, very important, and this is what our new knowledge is helping us to understand. Because if you've not had a good night's sleep, then the next day is a miserable thing. And, in fact, if you're not feeling rested and refreshed, there is no question patients will feel more pain. They will be more irritable. They will be more anxious. So we know that sleep is a very important factor.

And these factors are very, very tightly interlinked. If you haven't slept well, you're more fatigued. If you're more fatigued, you will feel more pain. If you have pain, you feel more fatigued. So there really is a very, very tight network with all of these important factors.

Lessening RA Pain by Managing Stress

Dr. Fitzcharles:

There are many different mechanisms to manage stress. Not all of us can afford to go and see a psychologist and talk about all of our problems, but we can use very simple mechanisms. And what I often tell patients is make sure that each single day you do something, or experience something that gives you pleasure. It might be nothing more than looking out of a window and looking at a beautiful cloud or looking down and appreciating one tiny little flower, and you keep that little memory for that day.

And as you think about that little memory of pleasure, there is no question it will just dampen down your stress. That's a very, very simple, little mechanism that one can use.

We use other things. We use yoga, we use biofeedback. We can use meditation. You can become much more sophisticated regarding stress management. But these things can be very easily incorporated into our daily life. A little bit of deep breathing, closing your eyes, these are very important, simple things that we can do.

The Right Ways to Use RA Pain Medications

Dr. Fitzcharles:

Finally, we have the medications that we use for pain. There are other medications we have for treating RA in general, but here I'm talking primarily about pain. And they can be divided into categories. We have simple analgesics, like acetaminophen. We have the anti-inflammatory agents. And finally, we have the stronger analgesics, which are agents that have opioid action, and they work similarly to the natural endogenous opioid mechanisms in our brain. So we have three categories of agents. And essentially, we move up through the categories depending upon the severity of the pain.

With the simple analgesics, particularly acetaminophen, we need to be concerned that we don't get an overdose, because there can be liver toxicity. So someone who is drinking alcohol on a daily basis should be cautious about using too much acetaminophen (because alcohol is also toxic to the liver).

The non-steroidal anti-inflammatory agents (NSAIDs) are wonderful agents which impact those inflammatory molecules in the joints. They are good. We have to use them with respect. They can all have some effect upon kidney function, some impact upon the gastrointestinal tract. They can have a problem with fluid retention. And very often patients will use an anti-inflammatory and say, 'You know. I'm just not thinking quite as clearly as I should.' And then finally, we have the cardiovascular effects, and there certainly is some concern (e.g., this is the reason Vioxx [rofecoxib] was taken off the market).

The third group of agents is the opioid or the stronger analgesics (i.e., narcotics). They are good pain relieving medications, but unfortunately they have important side effects including lots of constipation, feeling tired, feeling groggy, feeling sleepy and nausea. We still don't have that magic medication that we're looking for.

Can Acupuncture or Massage Reduce RA Pain?

Dr. Fitzcharles:

What do we think about acupuncture and massage? There's no question as Western physicians we don't totally understand acupuncture. However, there is more and more scientific evidence that acupuncture absolutely has some impact on pain. We've recently had some very nice studies that have been published from England and Germany on the effect of acupuncture on osteoarthritis of the knee, and acupuncture absolutely will dampen down and modulate pain.

Number two, a very important aspect of how well these treatments work is dependent upon the patient's belief in the treatment. So if the patient - and this is a beautiful study; it was done in Germany - went into the treatment with the belief that they were going to do well, they did well. If their belief was a little less enthusiastic, they tended not to do so well. If you honestly believe something is going to work, the chances are that it is going to do something to pain.

What about massage? Massage is a wonderful means of reducing and relaxing muscle tension, and it often helps patients to get over a very acute, severe episode of pain. However, massage on its own will not have a prolonged effect. Massage will work if the patient increases their mobility and increases their physical activity. Massage linked with exercise is a wonderful modality. Massage on its own is really not going to have a long lasting effect.

More on Rheumatoid Arthritis Symptoms and Treatment

If you'd like to know more about recognizing and managing rheumatoid arthritis pain, listen to the entire show and hear Dr. Fitzcharles answer questions from the audience.

For more information on rheumatoid arthritis, check out these HealthTalk resources:

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